| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
389 |
288 |
$181K |
| D1110 |
Prophylaxis - adult |
1,399 |
1,396 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,745 |
1,738 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
1,635 |
1,621 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,686 |
3,378 |
$81K |
| D4341 |
|
971 |
264 |
$67K |
| D9430 |
|
1,924 |
1,731 |
$61K |
| D1120 |
Prophylaxis - child |
1,309 |
1,299 |
$51K |
| D4910 |
|
633 |
630 |
$49K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
381 |
266 |
$44K |
| D0330 |
Panoramic radiographic image |
1,509 |
1,503 |
$44K |
| D0350 |
|
3,331 |
869 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,915 |
1,904 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
316 |
188 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,091 |
1,085 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
106 |
$12K |
| D4342 |
|
168 |
52 |
$7K |
| D0272 |
Bitewings - two radiographic images |
424 |
424 |
$5K |
| D2952 |
|
50 |
39 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
121 |
$5K |
| D3221 |
|
28 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
46 |
$815.40 |
| D1999 |
|
165 |
161 |
$45.00 |
| D1310 |
|
65 |
65 |
$0.00 |